Free Braces Sign Up

All information remains confidential and will not be used to generate spam to your email address. Nor is any information ever sold to third parties!!

To access the doctor list anonymously simply Click the submit button at the bottom of the page without completing the form. This will direct you to the links containing the Free Braces Doctor lists in your region.

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Please tell your friends and family about us!

There is a section in the online form for you to ask questions. If you have additional questions you can Reach us at info@freebraces.net

(Any questions about qualifying for the free braces program can only be answered by the Free Braces Doctors. Call one of them to schedule an exam to determine if your problems meet the program requirements.)

First Name:

Last Name:

Address Street 1:

Address Street 2:

City:

Zip Code:

(5 digits)

State:

Daytime Phone:

Evening Phone:

Email:

How old is the patient seeking treatment?:

List any dental insurance or state funded medicaid (Medi-Cal) benefits.:

Has the patient recently had a braces exam?:

If yes what did the doctor say was needed?:

Please give the names of any other family members under 21 also needing appointments?:

If there are any significant health problems we should be aware of list them here:

When was the last time you visited the dentist?:

Please describe the problem with the tooth alignment and/or bite?:

What internet search website did you use to find our website?:

If you don't qualify for the Free Braces and were offered a discount plan for braces, how much could you afford per month?:

Are there any questions that we can answer for you when we contact you?: